Collaboration Pathways for

Infants and Families Affected by

Substance Use Disorders:

Lessons From New Jersey

April 2019

Acknowledgments

This report was prepared for the Substance Abuse and Mental Health Services Administration

(SAMHSA) and the Administration on Children, Youth and Families (ACYF), Children’s

Bureau by the Center for Children and Family Futures (CCFF) under contract

#HHSS270201700001C. Points of view or opinions expressed in this report are those of the

authors and do not necessarily represent the official position or policies of SAMHSA or ACYF.

CCFF would like to thank Christine Scalise of the Division of Mental Health and Addiction

Services and Mollie Greene of the Department of Children and Families, and their respective

agencies, for the information and support provided and for their continued efforts to improve

outcomes for children and families. Neither is responsible for CCFF’s interpretations

in this review.

Contact Information

Website: https://ncsacw.samhsa.gov

Toll Free: 1–866–493–2758

Email: ncsacw@cffutures.org

Table of Contents

Introduction and Overview ............................................................................................................. 1

About This Case Study ............................................................................................................... 1

New Jersey IDTA and IDTA-SEI Goals .................................................................................... 2

Organization and Context of the New Jersey IDTA Efforts ........................................................... 3

Leadership and Partners .............................................................................................................. 3

Related Reforms That Paved the Way for IDTA ........................................................................ 4

Other Important Contextual Events Affecting the IDTA Projects.............................................. 5

Major Practice and Policy Accomplishments ................................................................................. 7

Drop-Off Analysis to Improve Treatment Engagement and Retention ...................................... 8

Statewide Substance Use Disorder Training for Child Welfare Workers .................................. 9

Case Management and the Recovery Support Model ................................................................. 9

Statewide Hospital Survey of Screening Practices and Related Data Analysis........................ 10

Implementing Plans of Safe Care for Infants With Prenatal Substance Exposure and Their

Families ..................................................................................................................................... 11

Challenges to Systems Change ..................................................................................................... 13

Barriers to Systems Change ...................................................................................................... 13

Tracking Outcomes Data That Adequately Reflects Progress .................................................. 13

Key Lessons .................................................................................................................................. 14

Looking Ahead: Next Steps and Ongoing Initiatives for the New Jersey Team .......................... 20

Conclusion .................................................................................................................................... 21

Appendices .................................................................................................................................... 23

Appendix A: Agencies Represented on the State Team ........................................................... 23

Appendix B: New Jersey Birthing Hospital Instructions and Surveys ..................................... 24

1

Introduction and Overview

In 2009, the state of New Jersey began working

with NCSACW on a number of technical

assistance (TA) projects to strengthen cross-

systems collaboration and improve the lives of

families in the child welfare system who are

affected by parental substance use disorders. Two

of these projects were part of NCSACW’s In-

Depth Technical Assistance (IDTA) program (see

sidebar). For a decade, New Jersey’s

achievements have encompassed a full range of

improvements to linkages among child welfare,

substance use disorder treatment providers, and

the courts broadly, and then moved to a more

targeted emphasis on strengthening agency

practices and policies specifically for families

with infants with prenatal substance exposure.

New Jersey’s IDTA initiatives built upon a

foundation of prior systems improvements that

increased the state’s readiness for innovation

among agencies and other stakeholders seeking to

improve outcomes for children, parents, and

families affected by substance use disorders.

About This Case Study

This case study highlights New Jersey’s progress

and achievements from the vantage point of the

New Jersey team and its partners at the

intersection of health care, family courts, child

welfare, and substance use disorder (SUDs)

NCSACW IDTA Program

Since its initial funding in 2002 by SAMHSA and

ACYF, Children’s Bureau, NCSACW has

provided an array of TA and training to federal

grantees and other state, tribal, and local

collaborative teams seeking to build stronger

linkages among child welfare, substance use

disorder treatment providers, and the courts. The

most intensive of these efforts is the IDTA

program, which has assisted 25 state, county, and

local jurisdictions.

In September 2014, NCSACW’s IDTA initiative

focused on substance-exposed infants (SEI) and

their families. The SEI program was developed to

help states respond to opioid use during

pregnancy, the increasing number of infants

entering out of home care, and a lack of

coordinated and ongoing services that are needed

to support infants, families, and caregivers during

the critical postpartum and infancy period. To

date, the targeted IDTA-SEI program has

supported 12 jurisdictions.*

With senior-level NCSACW staff and consultants

assigned to work with a state, county, or tribal

interagency team for an average of 18 to 24

months, the IDTA projects have reformed

interagency practice and state policy in ways that

have improved outcomes and made systems

changes in each of these sites. For more

information on the IDTA programs, visit the

NCSACW website at https://ncsacw.samhsa.gov.

* The IDTA-SEI program recently changed its

name to the IDTA-Infants with Prenatal

Substance Exposure program. However, this case

study uses the original SEI designation that was

employed during New Jersey’s project.

2

treatment, as well as the NCSACW staff who participated most actively in New Jersey’s work.1

The case study is not intended to provide an exhaustive, detailed review of all components of the

multi-year, multi-faceted TA effort. Rather, it describes the context of New Jersey’s IDTA

projects, the accomplishments achieved, the barriers encountered, a set of lessons for further

practice, and state and local policy reform in these arenas.

NCSACW believes the lessons from New Jersey provide useful information and guidance to

other states and localities seeking similar progress in achieving shared outcomes for all families

in their child welfare and other state agency caseloads affected by parental SUDs and especially

for infants affected by prenatal exposure. What New Jersey achieved—and what the state

partners continue to work on beyond the IDTA projects—has brought considerable progress

toward better outcomes for these families.

New Jersey IDTA and IDTA-SEI Goals

New Jersey’s two IDTA projects were linked in significant ways, with the second targeted

substance-exposed infant (SEI-IDTA) effort building on the first broader cross-systems

improvement effort and because a core group of New Jersey officials were actively involved in

both IDTA initiatives.

In 2009, at the outset of the initial IDTA project, New Jersey’s overarching goal was to

implement a statewide coordinated plan to work with families involved with the child welfare

system and affected by SUDs. More specifically, the state team’s priorities were to develop:

1 This case study is based on the following major sources of information: (1) a review of more than 1,000 pages of

reports that the New Jersey team and NSCACW staff prepared during the IDTA projects, (2) semi-structured

interviews with three key New Jersey team members shortly after IDTA ended, and (3) interviews and

correspondence with five NCSACW staff most actively involved in the New Jersey IDTA projects.

•

•

•

Capacities for collecting, analyzing, and managing cross-system child welfare and

substance use disorder treatment data

A statewide, cross-systems child welfare and substance abuse training program for child

welfare and substance abuse treatment staff

A recovery support program to be piloted in at least one site

3

In 2014, in applying for the second, more targeted IDTA project focused on improving practice

and policy for families with SEI, the New Jersey team’s stated goal was: To develop uniform

policies/guidelines to address the entire spectrum and improve collaboration to address the

multiple SEI intervention opportunities, from pre-pregnancy counseling continuing through a

child’s developmental milestones and parental treatment.

The state team refined its IDTA-SEI goals further in 2016 to include the following:

Organization and Context of the New Jersey IDTA Efforts

Leadership and Partners

The Division of Mental Health and Addiction Services (DMHAS) within New Jersey’s

Department of Human Services (DHS) was the lead agency for both IDTA initiatives. The state-

based leadership of these two IDTA efforts overlapped significantly, which proved to be an asset

in establishing continuity across efforts and a productive working relationship with the

NCSACW. The state project liaison from DMHAS had a longstanding relationship with

NCSACW.

The primary partnering agencies involved were the State of New Jersey’s Division of Addiction

Services (DAS); the Division of Child Protection and Permanency (DCPP)2 in the Department of

Children and Families (DCF); and, for the first initiative, the Administrative Office of the Courts

2 DCPP was formerly known as the Division of Youth and Family Services (DYFS). The new division name is used

for this case study.

•

•

•

Increase perinatal SEI screening at multiple intervention points (i.e., the health system,

the substance use disorder and mental health system).

Increase the rate at which women who screen positive for prenatal substance use (using

the 4P’s Plus© validated screening instrument) are connected to assessments through

leveraging existing programs and policy mechanisms and establishing formal safety net

measures.

Increase the rate at which women with substance exposed infants and other eligible

children receive early support services through leveraging existing programs and policy

mechanisms.

4

(AOC). These primary partners met monthly and held monthly calls with the NCSACW Change

Liaison, with additional calls scheduled as needed. Ad hoc committees were formed to work on

specific objectives. Members of the Core Team were also charged with keeping their

department’s leadership informed about and engaged in the team’s progress. State leaders from

DCPP, DCF, DAS, and AOC met as needed to discuss the Core Team’s work.

In the SEI project, the State Department of Health (DOH) also played an important leadership

role, with the sustained involvement of its then Deputy Commissioner throughout the project.3 In

addition, the DCF Commissioner recruited a staff member with practice and policy expertise in

the intersections of child welfare and SUDs to oversee the SEI-IDTA project. These two

individuals, along with the Women’s Treatment Manager from the Division of Mental Health

and Addiction Services led this initiative. All three were members of the State Opioid

Workgroup, which met quarterly and essentially served as the Executive Leadership Committee

for the SEI-IDTA initiative. More than 50 people from multiple systems and agencies were

engaged over the life of the SEI-IDTA initiative at both state and local levels. DCF staff also

included early childhood-focused officials, which deepened involvement on related issues, such

as linkages to Head Start and early intervention services. Increased involvement of hospitals and

other medical providers also occurred during the SEI-IDTA project, with county-level partners

engaged in both IDTA projects. The New Jersey agency partners are listed in Appendix A:

Agencies Represented on the State Team.

Related Reforms That Paved the Way for IDTA

The New Jersey team benefitted from earlier reforms and innovation that provided a strong

foundation of readiness for the IDTA efforts. Two of the most important efforts were (1) the

development of screening and assessment contractual support under the state’s Child Protection

Substance Abuse Initiative (CPSAI), which strengthened local child welfare agencies’ capacity

to arrange for timely SUD assessments and referrals to treatment and (2) the innovative statewide

implementation of the 4P’s Plus prenatal substance use screening tool, which was embedded

within the established Pregnancy Risk Assessment instrument, the statewide screening form used

3 In 2018, after the IDTA efforts concluded, the Deputy Commissioner left the state DOH to become Chief

Executive Officer of a major New Jersey foundation that is dedicated to improving the health and well-being of

vulnerable populations in New Jersey, including a focus on early childhood and sustainable systems reform.

5

for all Medicaid prenatal care. This foundation was a result, in part, of an earlier separate training

in universal screening initiative for healthcare providers conducted by a recognized national

expert that predated the IDTA process. Beginning in 1999, the state expanded the training

sessions with South New Jersey physicians to include other hospitals, state Medicaid officials,

and managed care organizations.

Other Important Contextual Events Affecting the IDTA Projects

The policy context affecting the two IDTA projects included some fundamental issues that most

states encounter, as well as issues that were specific to New Jersey. New Jersey accepted

Affordable Care Act expansions of Medicaid, and a greater emphasis on managed care also took

place during the IDTA efforts. As an early Medicaid expansion state, treatment expansion and

access to treatment were major state goals. Medicaid covers a high percentage of births with

prenatal exposure, and initial prenatal screening targeted pregnant women who were on

Medicaid. As such, engagement of Medicaid and managed care entities played a major role in

the IDTA work. Moreover, as the number of newborns with neonatal abstinence syndrome

(NAS) was increasing dramatically, with the vast majority of them covered by Medicaid,

hospital costs for caring for these infants also increased dramatically. The state team recognized

it was to their advantage to work with other partners on identifying pregnant women with SUDs

early, connecting them to appropriate treatment covered by insurance, and stabilizing and

preparing mothers for the birth event.

During both phases of IDTA, New Jersey’s child

welfare system was operating under a court order,

which resulted from earlier class action suits against the

state. The court order emphasized smaller caseloads for

child protection workers, more foster homes, and an increase in adoptions. The state established

a new cabinet-level DCF in 2006 and adopted a child welfare reform plan in 2004 to respond to

4 Sources: U.S. Department of Health and Human Services, Administration for Children and Families,

Administration on Children, Youth and Families, Children’s Bureau. (2018). Child maltreatment 2016.

https://www.acf.hhs.gov/sites/default/files/cb/cm2016.pdf

and U.S. Department of Health and Human Services, Administration for Children and Families, Administration on

Children, Youth and Families, Children’s Bureau. (2017). Adoption and foster care analysis and reporting system

(AFCARS) Foster Care File FY 2016. Ithaca, NY: National Data Archive on Child Abuse and Neglect [distributor].

https://ndacan.cornell.edu

In 2016, New Jersey’s child welfare

system had 8,264 substantiated

cases of child abuse or neglect and

11,019 children residing in out-of-

home care.4

6

these issues. The IDTA efforts sought to build on these developments, with a greater emphasis

on parental substance use disorders as they affected the child welfare caseload. In 2015, the

settlement agreement was modified, recognizing that the state had achieved significant child

welfare system improvements and that some of the requirements were not feasible or did not

reflect current child welfare best practice. The effects of the court order on the IDTA projects are

discussed in Section V: Key Lessons.

The goals and results of the IDTA-SEI project were also affected by the opioid crisis. New

Jersey is among those states most affected by opioid misuse, with overdose deaths statistically

higher than the national average in 20165 and significant increases in cases of NAS.6 These

concerning trends provided a greater spotlight for the IDTA-SEI project.7 The Governor at that

time chaired the President’s Commission on Combating Drug Addiction and the Opioid Crisis,

convened by the new federal administration in 2017. He also led a separate state task force to

develop policy responses to the opioid crisis in New Jersey, which produced 25

recommendations for action in September 2017. Two of those recommendations explicitly

referenced prenatal exposure as requiring immediate action. Other recommendations included

increasing the number of recovery coaches in treatment agencies, expanding residential

treatment, and expanding supportive housing. All of these recommended changes aligned with

the goals that both IDTA projects had identified to address system challenges.

In addition, the state was affected by the passage of the Comprehensive Addiction and Recovery

Act of 2016 federal opioid-related legislation and appropriations, including changes in the Child

Abuse Prevention and Treatment Act (CAPTA) concerning notification of and response to

5 In 2016, the rate of opioid overdose deaths in New Jersey was 23.2 per 100,000, which was statistically higher than

the U.S. rate of 13.3 per 100,000. Source: Hedegaard, H., Warner, M., and Miniño, A. M. (2017). Drug overdose

deaths in the United States, 1999–2016. NCHS Data Brief, no. 294. Hyattsville, MD: National Center for Health

Statistics. https://www.cdc.gov/nchs/data/databriefs/db294.pdf

6 Between 2010 and 2015, the incidence of NAS among New Jersey hospital births increased from approximately

4.9 to 7.1 per 1,000 live births. Source: New Jersey Department of Health (2017). New Jersey Birthing Hospitals

Survey: Substance exposed infants (SEIs) and their mothers. The New Jersey Department of Health also reported

that from 2008 to 2016, cases of NAS doubled to 685 babies diagnosed in the state

(https://nj.gov/health/news/2018/approved/20180409a.shtml).

7 National Center on Substance Abuse and Child Welfare (2017). Substance-exposed infants: A report on progress

in practice and policy development in states participating in a program on in-depth technical assistance September

2014 to September 2016. https://ncsacw.samhsa.gov/files/IDTA_Executive_Summary.pdf

7

infants identified as affected by prenatal exposure.8 The requirement for plans of safe care for

these infants and their families became a focal point in the IDTA-SEI project and in New

Jersey’s ongoing efforts as of 2016.

Finally, several parallel initiatives were underway within state agencies at the same time as the

two IDTA projects. These included expanded home visitation, an early childhood-focused

project in three counties, and the development of a child welfare data hub based at Rutgers

University.9 For the most part, these related initiatives operated separately from the two IDTA

projects.

Major Practice and Policy Accomplishments

Through its two IDTA efforts, New Jersey achieved a number of practice and policy

improvements to meet their stated goals (outlined in Section I). The major accomplishments of

the first round of IDTA included enhanced capacities for cross-systems data collection, analysis,

management, and preliminary planning for a recovery support model. In the first round of IDTA,

NCSACW worked with DCF to develop a curriculum for child welfare staff on understanding

parental substance use. Following the SEI-IDTA initiative, an advisory group was convened to

guide the development of a substance use disorder certificate program for the New Jersey DCF

Child Protection and Permanency workforce. The certificate program will build capacity for

supporting families who are child welfare involved and affected by substance use and co-

occurring mental health disorders. This statewide cross-systems training effort is in progress at

the writing of this case study with a NCSACW staff member serving on the advisory group as a

subject matter expert.

The major accomplishments of the second round of IDTA included a hospital survey of

substance use screening practices for pregnant women and the care of infants with prenatal

exposure, the development and funding of a case management and recovery support model for

8 These changes were included in the Comprehensive Addiction and Recovery Act passed in 2016 in response to the

opioid epidemic.

9 The New Jersey Child Welfare Data Hub is a collaboration between the New Jersey DCF and the Child Welfare

and Well-Being Research Unit at the Rutgers University School of Social Work. The Data Hub seeks to improve the

lives of children and families by disseminating New Jersey child welfare and well-being data. More information is

available at https://njchilddata.rutgers.edu.

8

opioid-dependent women, changes in regulations regarding the reporting of infants affected by

prenatal substance exposure, and more extensive outcomes and cost analyses related to infants

with prenatal substance exposure. These accomplishments are discussed in more detail as

follows.

Drop-Off Analysis to Improve Treatment Engagement and Retention

A major product of the first IDTA project was a drop-off analysis to assess the points in the

systems that families in the child welfare system who are referred for a substance use disorder

assessment and subsequent treatment services either do not engage in or drop out of services. As

the figure below illustrates, the analysis of data from fiscal year 2009–2010 indicated that more

than 13,800 child welfare cases referred to substance use screening agencies resulted in 2,590

entries to treatment and 1,282 completed treatment (not including those still in treatment).

Importantly, the drop-off analysis also showed that 41 percent of those referred to treatment

entered treatment.10

State staff described the importance of the drop-off analysis as “helping us to see things

differently.” They indicated that this graphic depiction showing the gradation from clients

screened to those completing treatment was a helpful way to assess engagement and retention of

10 Data were drawn from two administrative datasets—the CPSAI database and the New Jersey Substance Abuse

Monitoring System—which are linked by a common identifier.

9

parents from the child welfare system in SUD treatment, following screening and referral from

the CPSAI contract agencies. The New Jersey team used this drop-off analysis tool to guide and

manage system improvements such as more face-to-face outreach and engagement during the

preliminary stages of the child welfare investigation and assessment process. The team’s efforts

were featured in a 2015 article in Child Welfare’s special issue on families in child welfare

affected by substance use.11

The New Jersey team also conducted a cross-system data inventory, which enabled team

members to gain a better understanding of the data being collected by the various partner

agencies other than their own. The data inventory process identified limitations with the data and

challenges with access, including a need for legal staff in state agencies to develop data use

agreements to facilitate sharing of data across agency boundaries.

Statewide Substance Use Disorder Training for Child Welfare Workers

As a result of IDTA, the New Jersey team developed and incorporated SUD education into the

training for new child welfare workers. This initial training evolved into four 1-day training

modules that are still provided to new workers and are in the process of being updated. In

addition, subsequent to IDTA, New Jersey is currently developing a more in-depth training

program for existing staff.

Case Management and the Recovery Support Model

During the initial IDTA effort, the recovery support model was developed but did not reach full

implementation as planned due to leadership changes and resource limitations. However, major

features of the model were incorporated in the IDTA-SEI effort. During IDTA-SEI, the Camden-

based team, which had been involved in earlier hospital-based SEI-linked reforms, sought to

develop a continuum of care—including increasing shared communication—for pregnant women

with SUDs and their infants. The team completed a walkthrough of their county’s system

(medical, substance use, and child welfare) for pregnant women. The walkthrough illustrated the

11 Traube, D. E., He, A.S., Zhu, L., Scalise, C. and Richardson, T. (2015). Predictors of substance abuse assessment

and treatment completion for parents involved with child welfare: One state’s experience in matching across

systems. Child Welfare, 94(5), 45–66. https://www.ncbi.nlm.nih.gov/pubmed/26827464

10

gaps between service systems and challenges that women experienced obtaining services. The

Camden team identified initial goals for building collaborative practice.

The larger New Jersey state team used Camden’s experience to develop a request for proposals

for the Maternal Wraparound Program (M-WRAP), issued through DMHAS, to provide

intensive case management, wraparound services, and recovery supports for pregnant and

postpartum women with opioid use disorders. Using state funding from DMHAS and DCF,

including funds from the now-current Governor’s opioid initiative, M-WRAP has been

implemented statewide in six regions.

Statewide Hospital Survey of Screening Practices and Related Data Analysis

During the second round of IDTA, the New Jersey

team conducted a survey of the state’s 50 birthing

hospitals regarding their practices for screening

pregnant women for substance misuse or abuse and

their identification and care of substance-exposed

infants (Appendix B). The team also surveyed 200

outpatient pediatric care providers working in the

birthing hospitals regarding assessment and care of

infants with NAS. The survey, which was completed in 2017, was an exemplary effort to

document current screening protocols and practices. This survey also documented NAS

treatment practices, billing codes used for NAS treatment, and hospital discharge practices. The

New Jersey team made a sustained effort to gain representative responses through professional

associations’ endorsement of the survey and encouragement to the hospitals and other medical

professionals. The team also addressed DMHAS’ data-sharing confidentiality concerns and

obtained institutional review board approval.

The survey results regarding prenatal and postpartum practices contributed in part to the state’s

development of M-WRAP. State staff pointed out how this information also laid a foundation for

their ongoing work to prepare for implementing plans of safe care as required by CAPTA. The

survey also revealed that while 94 percent of responding hospitals said they were very or

extremely confident in their effectiveness at identifying and managing prenatally exposed

infants, there was substantial variation and a lack of consistency across hospitals in how they

The purpose of this survey was to gain

a better understanding about protocols

and practices used by New Jersey

birthing hospitals and providers in the

care of SEIs and their mothers. Despite

the recommendations put forth by the

American Academy of Pediatrics to

manage SEIs, it is unclear whether

these guidelines are being used widely

or consistently.

11

screened for and identified prenatal substance exposure. Moving forward, the interagency team

plans to use the hospital survey findings to establish standards for best practices for screening

and reporting.

In addition to conducting the hospital survey,

the New Jersey team assembled data on

Medicaid costs of hospitalizations related to

NAS and reviewed Medicaid prenatal

screening and referral data to map the

frequency of screening across the state.

Overall, the team found high utilization (over

80 percent) of screening using the 4P’s Plus

tool by private physicians and hospital staff

serving pregnant women on Medicaid. Still, the mapping enabled the team to identify and target

low utilization areas to increase prenatal screening for substance use. Moreover, the mapping

identified that no data were being collected on positive screens to determine if women who were

assessed as needing treatment actually entered treatment. The New Jersey team noted that the

state’s managed care organizations now require prenatal screening for substance use in order to

collect reimbursement for prenatal care. The team intends to eventually link Medicaid data with

substance use treatment data to learn about the frequency of mothers with positive screens

accessing treatment.

The New Jersey IDTA efforts were able to

build on the successes of prior screening

reforms and carry that momentum forward.

The latest data available from the statewide

hospital survey and Medicaid sources

indicates that the 4Ps Plus screening tool is

used in a sizable majority of all prenatal care

funded by Medicaid in New Jersey. This

represents the furthest expansion of use of a

validated prenatal screening tool in any state

known to NCSACW.

Implementing Plans of Safe Care for Infants With Prenatal Substance Exposure

and Their Families

In the year following the IDTA-SEI engagement, a workgroup with team members that included

pediatricians specializing in neonatology and child abuse and neglect, child and adolescent

psychiatrists, and child welfare nurse care managers12 to respond to the federal legislative

language in the CAPTA amendments concerning the definition of infants “affected by substance

abuse.” DCF has begun counting notifications from the hospitals that match these new

12 DCF’s Nurse Care Management Program is operated through a memorandum of agreement with the Rutgers State

University School of Nursing.

12

definitions. Prior to the 2016 Comprehensive Addictions Recovery Act, New Jersey did not have

state laws related to reporting infants identified as affected by substance abuse. However, in

January 2018, DCF and DOH jointly issued new regulations setting forth criteria for hospitals to

define and notify DCF of substance-affected infants, to provide service to parents of such infants,

and to bring New Jersey into compliance with CAPTA requirements.13 A recommendation is

currently pending for the executive team that oversees CAPTA implementation to continue with

the IDTA-SEI efforts. At present, the executive team is focused on maternal mortality and

morbidity, with SUD treatment for SEI-related problems as a priority within that overall

emphasis.

As part of the IDTA-SEI effort, the New Jersey team also conducted a separate comparative

analysis of child welfare outcomes of infants and children with prenatal exposure compared to

those without prenatal exposure. The analysis focused on differential rates of child removal,

reunification, and re-entry to out-of-home care. State staff found that infants and children with

prenatal exposure had higher rates of removal, a longer time to reunification, and higher rates of

re-entry than those of non-exposed children. These findings were an important factor in gaining

support for the interagency team’s efforts to respond to prenatal exposure through implementing

plans of safe care. Work continues in the Camden site where efforts are underway to link the

implementation for plans of safe care to the county’s existing cross-systems collaborative efforts.

13 New Jersey Administrative Code. § 8:43G-2.13 Child abuse and neglect and substance-affected infants. Amended

by R.2018 d.018, effective January 16, 2018. See: 50 N.J.R. 283(b).s

Institutionalizing Change

The New Jersey team is well positioned to sustain its practice and policy changes with the

expressed commitment of state agencies for continued cross-systems training, funding of M-

WRAP implementation of plans of safe care, and expanded and enhanced data collection to

monitor progress. For example, beginning July 1, 2019, Medicaid will reimburse providers for

case management and recovery coach services in the SUD treatment system.

13

Challenges to Systems Change

The progress that the New Jersey team made was not without its challenges, described as

follows.

Barriers to Systems Change

During the course of its efforts, the New Jersey team encountered specific barriers that are

commonly seen in large-scale collaboration efforts. These challenges included reorganization of

state agencies, turnover in the Governor’s office with new senior agency leadership, challenges

to data sharing across agency boundaries (in part due to confidentiality concerns and variable

data collection and reporting processes), and an emphasis on separate innovations and reforms

that were part of the court order in the state’s child welfare system.

Tracking Outcomes Data That Adequately Reflects Progress

As outlined in Section III, the New Jersey team made substantial progress on collecting and

analyzing new and existing administrative data on SUD screening practices for pregnant women,

child welfare outcomes for infants with prenatal substance exposure, and the Medicaid costs

associated with hospitalization of infants diagnosed with NAS. These data helped inform the

team’s policy and practice improvements.

Yet, these data alone do not adequately reflect the deeper impact that the IDTA efforts may have

had on improving outcomes for children, parents, and families affected by SUDs. Obtaining

comprehensive outcomes data can be challenging—for any site—and requires sustained

commitment from all partners to systematically collect and share needed outcomes data on the

families involved in multiple service systems.

The IDTA timeframe of 18 to 24 months does not allow for measuring long-term outcomes for

children, parents, and families. However, states can identify the outcomes they want to measure

and begin to collect and report system outcomes.

14

As the New Jersey team continues its efforts and the initiatives further mature, indicators the

team should strive to track to more adequately measure the state’s success might include:

•

•

•

•

•

•

•

Earlier and expanded identification of substance use during pregnancy through prenatal

screening

Improved engagement and retention in treatment for parents in the child welfare caseload

affected by SUDs

Increased admissions of pregnant and parenting women in treatment over baseline levels

Expanded engagement of parents with substance abuse issues in home visiting programs

More consistent hospital notifications to child protective services

Increased referrals by hospitals and child welfare services to early intervention services

(IDEA Part C agencies) for infants affected by prenatal substance exposure

Reduced lengths of stay in the neonatal intensive care unit for infants affected by prenatal

substance exposure

Key Lessons

A set of lessons emerged from the New Jersey IDTA experience that NCSACW believes are of

value to other jurisdictions seeking to implement state-based practice and policy reforms to

better serve families affected by parental SUDs and, in particular, infants with prenatal substance

exposure. These lessons, discussed as follows, center on four key areas: contextual barriers,

leadership, data and outcomes, and the interconnected nature of change components. This section

concludes with a fifth and final lesson from NCSACW staff about the process of providing

intensive TA to jurisdictions engaged in systems improvement initiatives.

A state’s or community’s context always matters when implementing systems improvements.

Shifts in the fiscal, legal, and leadership arenas as well as parallel reform initiatives almost

always affect efforts to change practice and policy—sometimes positively, sometimes

negatively. Yet, many sites do not always identify and tackle the adverse effects of contextual

issues head-on in planning, either because focusing on barriers may seem overly negative, or

1 Context matters in change efforts and requires a proactive response

15

because barriers may be seen as outside the control of the site team. As a result, collaborative

teams often deal with barriers reactively rather than anticipating and handling them proactively.

In addition to contextual issues, certain individuals or “blockers” may also act as barriers to

systems improvement efforts. Blockers can come from one or more partner agencies—attorneys,

judges, treatment agencies, child welfare workers, and managed care. Effective leadership that

builds trusting relationships can help the team identify barriers and blockers early and clearly

enough to develop strategies to overcome or reduce such obstacles.

In New Jersey, the lead site team members knew state agencies well enough to be able to

anticipate issues likely to recur from prior reform efforts, including information sharing and a

lack of data on key processes and outcomes. They also had well-established personal and

professional networks that enabled them to work with potential blockers over time. The lesson

for other jurisdictions is the importance of the interagency team anticipating barriers explicitly

and addressing them proactively.

Persistence also matters in responding to contextual barriers. The legal complaint against New

Jersey’s child welfare system was initially settled in 2004, but monitoring continues under the

Sustainability and Exit Plan. New Jersey officials attribute some of the most important practice

changes during this time to the settlement and the state’s continuing efforts to strengthen services

to children in the child welfare system. However, the primary focus of the court order and

monitoring was on the array of services (e.g., provision of mental health services) and outcomes

for children in foster care, and not on issues related to parental SUDs and infants affected by

prenatal substance exposure in the child welfare system specifically. An unrelated 2017 report on

infants and toddlers by a statewide advocacy agency did not include prenatal substance exposure.

Subsequently, New Jersey identified the need to engage in IDTA-SEI, prioritizing early

identification of pregnant women with SUDs, expanding wraparound services to support

engagement in treatment, and increasing the awareness of the state opioid workgroup on the

effects of prenatal substance exposure on infants. It is noteworthy that in 2014, DCPP hired a

Director of Clinical Services, who was a critical member of the IDTA state team, to focus on

substance use disorder issues in the child welfare system.

16

2 Committed and consistent leadership is essential to affect systems change

•

•

•

•

•

•

•

•

The New Jersey IDTA efforts were greatly aided by the active engagement and commitment of

two state officials from DMHAS (within DHS) and DCPP (within DCF) with deep experience in

interagency collaborative efforts to respond to the needs of children and families involved with

child welfare due to parental substance use disorders. These individuals:

Were highly skilled in identifying and framing difficult issues that the team needed to

respond to (with the strategic help of NCSACW staff as needed);

Were able to convene key stakeholders as needed to increase awareness about the

prevalence of the problem, identify barriers, develop strategic plans, and implement

practice changes;

Had a deep understanding of the challenges facing state agencies that seek to work

together more effectively across agency boundaries;

Recognized the importance and necessity of engaging independent community systems

outside state government—such as hospitals, maternal and child health, and managed

care—to effectively serve families;

Had access to the top officials in their agencies and were able to secure their support and

leverage resources when needed;

Had extensive knowledge and understanding of both the child welfare and treatment

systems from many years of cross-systems’ experience;

Were effective “connectors” in that they did not always take the lead in making the case

for change, but ensured that the stakeholders and agency leaders who could make change

possible were in the room at the right times; and

Were able to devote significant time to the IDTA efforts, while handling their other

agency responsibilities at the same time.

As previously mentioned, state leadership both within and outside of the IDTA efforts was

significant in advancing New Jersey’s reform agenda. For the IDTA-SEI effort, for example, the

Governor had a visible national role on some important elements of the IDTA-SEI agenda. The

Deputy Commissioner of Health also was a genuine agency leader, a pediatrician who

understood SEI issues in considerable depth and who brought great credibility with professional

17

peers in the private sector. His efforts to establish links to the Medicaid staff and the results of

the NAS cost study resulted in more emphasis on cost issues than in most states. His leadership

in ensuring that costs were part of the discussions may have contributed to the managed care

organizations’ policy change to reimburse for comprehensive care that includes required prenatal

screenings for substance use.

3 Institutionalized outcomes data are needed to adequately assess results

As this case study has highlighted, the New Jersey

IDTA team made great strides in collecting and using

existing and new data to document the prevalence of

SUDs in the child welfare caseload and current

practices for identifying and responding to infants with

prenatal substance exposure. However, one-time, ad

hoc collection of data on prevalence or practice differs

substantially from routine, institutionalized data

sharing and analysis that tracks improvements in outcomes over time to make the case for

needed practice and policy changes.

Changing the process of agency interactions is hard; keeping final outcomes and net resources in

view throughout the process is harder. Any statewide reform initiative will likely need new data

on outcomes and baselines to learn how to target resources better. It may also need to establish

better connections among agencies and other partners to improve the team’s collective capacity

to track how many families successfully move from one system to another—or how many do

not. In New Jersey’s case, the drop-off analysis helped to build such capacity. Measuring child

welfare and treatment outcomes would close the loop on such an analysis and is essential to

understand the impact of related process improvements (e.g., earlier identification and

screening).

In the most recent reporting of

Adoption and Foster Care Analysis

and Reporting System data for 2016,

New Jersey staff identified to child

protective services higher levels of

child removals associated with

parental substance use (40.5 percent)

than the national average (34.5

percent).14

14 Source: U.S. Department of Health and Human Services, Administration for Children and Families,

Administration on Children, Youth and Families, Children’s Bureau. 2017. Adoption and foster care analysis and

reporting system (AFCARS) Foster Care File FY 2016. Ithaca, NY: National Data Archive on Child Abuse and

Neglect [distributor]. https://ndacan.cornell.edu

18

In New Jersey, a set of performance measures to assess the impact of their innovative practice

changes is still emerging. The IDTA initiative introduced a data template with specific data

points that could establish baselines and measure long-term outcomes. Their next phase (post-

IDTA-SEI) is to move toward a dashboard of the most important measures of impact that is

institutionalized and reviewed on a regular basis by senior officials. That critical task needs to

continue, recognizing that measuring the results of statewide implementation of systemic

practice and policy changes over time must be sustained beyond the duration of any given TA

initiative. Achieving interagency review of shared outcomes will require team members to

achieve clear consensus around interpretation of 42 CFR confidentiality requirements.

4 The various components of systems change are interconnected

The lessons from the New Jersey IDTA initiatives indicate that systems change to improve

outcomes for families served among multiple human services agencies is rarely about a single,

isolated part of the system. Data components, training components, funding, and the changes in

practice all interact in complex patterns. Yet, often, a site team may focus on only one of these

within their respective system without examining how they interact. In New Jersey’s case, the

state team learned from the drop-off analysis that screening of parents for SUDs did not

necessarily link to treatment entry or completion. The team’s progress in the form of better

screening and engagement at the front end of the child welfare system led to a demand for

changes at the front end of the treatment system (i.e., contracted peer specialists who are co-

located in child welfare offices) to further improve client engagement. Subsequent changes to

improve treatment access (and quality) resulting from better screening are emerging. The

M-WRAP funding efforts will add to the capacity of family-centered treatment for the 240

women it serves. The team is now focused on efforts to ensure collaboration among the SUD

treatment and early childhood systems. An ongoing challenge for New Jersey will be to make

these links explicit and develop measurement systems to track their impact over time.

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5 IDTA tools and processes help teams drive change

In reviewing the role of NCSACW staff in providing

TA and how they worked with the New Jersey team,

state officials mentioned guidance on developing and

implementing plans of safe care consistent with

guidance from the Children’s Bureau Information

Memorandums and Program Instruction. Additionally,

NCSACW and CCFF TA tools, the drop-off analysis

and the systems walkthrough were especially helpful

IDTA process improvement strategies. A system walkthrough is a proven process designed to

assess the effectiveness of the system in achieving its desired results or outcomes, such as family

reunification, successful treatment completion, and child safety by ensuring that children are

living in safe and stable environments. Participants conduct a virtual walkthrough of the

identified system, providing all key stakeholders with: (1) a good understanding of the system as

it currently exists; (2) identifying any problem areas (e.g. inconsistency of referrals, delays in

accessing treatment, lack of services/involvement from critical stakeholders, problems with

engagement and retention, and lack of communication across systems); and (3) generating ideas

for improving organizational processes. The system walkthrough conducted in New Jersey

highlighted different identification and treatment practices occurring at prenatal care providers

and hospitals across the community. It also highlighted the lack of information sharing about

substance use and treatment engagement during the pre- and post-natal periods.

One team member commented, “We did not feel that the NCSACW came in and told us what to

do, but entered into problem-solving with us…. Implementing the Plans of Safe Care would be

very difficult without the help we received from the NCSACW staff.”

The TA is helping us move forward

some significant projects (e.g.,

hospital birth survey, a community

pilot program, a statewide RFP for

the Maternal Wraparound Program)

providing us with many resources

that will capture all elements for a

best practice model.

New Jersey team member

20

The New Jersey team also provided useful advice for future TA directions and methods. Their

suggestions included:

•

•

•

Increase the number of onsite visits to help build relationships between core team

members, increase face-to-face dialogue between partners, and help facilitate practice

change.

Ensure that individual IDTA project periods are for at least two years.

Develop a web-based discussion forum in which states can ask and respond to questions.

•

Looking Ahead: Next Steps and Ongoing Initiatives for the New

Jersey Team

The New Jersey team is poised to continue and expand the progress it has made in several ways:

Expanded Training. A post-IDTA-SEI

follow-up training project was launched in

March 2018 to develop a certificate program

for groups of 25 DCF staff at a time that

would equip them to work more effectively

with SUD treatment agencies and

professionals. The advisory group formed to

develop the training curriculum emphasized

the need for staff to be more trauma-

informed, understand the stigma attached to

SUDs, effectively and appropriately share

New Jersey’s prevalence of removals of

infants under the age of 1 year is headed

in the right direction, but still needs

improvement. Data show removals

declined from a peak of 23.5 percent in

2009 to 20.9 percent in 2016. In

contrast, the national rates increased

from 16.5 percent to 18.0 percent during

that same timeframe. State staff are

continuing to work to improve these

numbers, based on further analysis of

the hospital survey findings and prenatal

screening data.15

information (within the limits of confidentiality requirements), and understand how court

timetables operate.

15 Source: U.S. Department of Health and Human Services, Administration for Children and Families,

Administration on Children, Youth and Families, Children’s Bureau. 2017. Adoption and foster care analysis and

reporting system (AFCARS) Foster Care File FY 2016. Ithaca, NY: National Data Archive on Child Abuse and

Neglect [distributor]. https://ndacan.cornell.edu

21

•

•

•

Sharing and Using Hospital Survey Data to Further Improve Practices. The state has

requested additional TA from NCSACW to further analyze and interpret the findings of

the hospital survey and use those data to support the development and implementation of

Project ECHO (Extension for Community Healthcare Outcomes). The goal of ECHO is

to continue responding to the causes and effects of prenatal substance exposure through

statewide adoption of best practice clinical care and community-based interventions to

support infants affected by substance exposure and their parents.

Ensuring the Provision of Medication-Assisted Treatment. In 2015, New Jersey was

awarded a 3-year SAMHSA grant for their Medication Assisted Treatment Outreach

Project.16 The state team identified pregnant women with opioid disorders and veterans as

their priority populations. The state team intends to use the grant to focus on effective

outreach and engagement strategies to ensure that these two target populations access

needed services.

Garnering New State Leadership Support. As the newly elected Governor took office in

2018, new state agency heads were appointed, including the head of DCF, who had prior

experience in New Jersey and with the first IDTA project. The new DCF commissioner

was active in earlier child welfare reform efforts and has expressed her support of the

goals of the SEI-IDTA project. The funding of a request for proposal for the M-WRAP

project and the potential for opioid-specific treatment funding under the 21st Century

Cures Act are also seen by state staff as positive signs of executive leadership support.

Conclusion

The New Jersey IDTA efforts set in motion changes with impressive breadth. Over time, as these

changes become institutionalized, they will affect thousands of infants and children, and

thousands of families in the child welfare, maternal and child health, and private medical care

systems. The changes in practice and policy sought by these TA efforts also raise the possibility

that professionals in dozens of agencies will change their daily operations and practice.

16 This grant was under SAMHSA’s Medication-Assisted Treatment—Prescription Drug and Opioid Addiction grant

program.

22

Such widespread systems changes will not result simply from multiple meetings across agency

lines, or the issuance of documents explaining how to implement changes that respond to the

causes and effects of prenatal substance exposure. Achieving such progress takes time; infusing

these changes throughout state agencies and among other key stakeholders’ practices will require

more time to move from an isolated project to institutionalized statewide policy. Successful

large-scale systems change further requires patience and persistence, along with leadership that

possesses both, aided by a clear vision of how systems can change to improve the lives of

children and families. NCSACW has been privileged to be able to work with such leaders in

New Jersey and around the nation, and we are grateful for what we have learned from and

with them.

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Appendices

Appendix A: Agencies Represented on the State Team

New Jersey Department of Human Services

(DHS)

• DHS Office of Program Integrity &

Accountability

• Division of Mental Health and

Addiction Services

• Division of Family Development

• Office for the Prevention of

Developmental Disabilities Child

Welfare

• Division of Medical Assistance and

Health Services

New Jersey Department of Children

and Families (DCF)

• Division of Family and Community

Partnerships

• Office of Early Childhood Services

• Office of Clinical Services

• Division of Child Protection and

Permanency

New Jersey Attorney General’s Office Administrative Office of the Courts

and Legal Services

New Jersey Department of Health

Maternal Child Health Unit

Office of Licensing

Division of Family Health Services

Substance Abuse Treatment Providers

• Jersey Shore Addiction Services

Healthcare

• Family Guidance Center: Family &

Children’s Services

• Organization for Recovery Health

Services

Other Healthcare Members

•

•

•

•

•

•

Weisman Children’s Rehabilitation Hospital

Central Jersey Family Health Consortium

South Jersey Perinatal Cooperative

Rutgers Fetal Alcohol Spectrum Disorders (FASD) Training Center

Rutgers School of Nursing, Maternal Child Health Services

FASD Clinical and Educational Representative

•

•

•

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Appendix B: New Jersey Birthing Hospital Instructions and Surveys

•

•

•

•

Instructions for Healthcare Provider Survey

Survey for Hospital Obstetric Leadership

Survey for Hospital Pediatric Leadership

Survey for Pediatric Primary Care Provider